i

Special Exposure Cohort Petition U.S. Department of Heaith and Human Services

under the Energy Employees Occupational Centers for Disease Control! and Prevention
Illness Compensation Act National Institute for Occupational Safety and Health

| . , OMB Number. 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 5 of 7

Basis for Proposing that Records and Information are Inadequate for individual Dose —
Complete Section F.

Complete at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than one entry.

Fi i) We have attached either documents or statements provided by affidavit that indicate that
radiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personal monitoring or through area

monitoring.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached

documentation and/or affidavit(s) indicate that potential radiation exposures were pot monitored.
Lotter Stom. Dow Chenuael Courrhager 0 -
Ltnion Carbide’ Shed States | Sher are nO
Petords foc employer had worked at

Mu She.

F.2 rf l/ We have attached either documents or statements provided by affidavit that indicate that
radiation monitoring records for members of the proposed class have been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, source term, or process

from the site where the employees worked.
(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that radiation monitoring records for members ofthe
proposed class have pre lost, altered illegally, or destroyed. y) -

tom Dow lt hemiral Kehr e Secuitrs

LL ae S

ele tords Lor  ennployve A had.
been telived or hed dvd or more
ers. Dedore Dow s  purthese o£ (lnon

flach A h vi Deen destoy 03 :

Part F is continued on the following page.

Name or Social Security Number of First Petitioner: _ _


Special Exposure Cohort Petition U.S. Department of Health and Human Services

undef the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National Institute for Occupational Safety and Health

. OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 7 of 7

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 300 minutes per response,
including time for reviewing instructions, gathering the information needed, and completing the form. If you
have any comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton
Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this
address. Completed petitions are to be submitted to NIOSH at the address provided in these instructions.
Persons are not required to respond to the information collected on this form unless it displays a currently
valid OMB number.

Privacy Act Advisement

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified of the
following:

The Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. §§ 7384-7385)
(EEOICPA) authorizes the President to designate additional classes of employees to be included in the
Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the
assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease
Control and Prevention. Information obtained by NIOSH in connection with petitions for including additional
classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory
Board on Radiation and Worker Health and HHS.

Records containing identifiable information become part of an existing NIOSH system of records under the
Privacy Act, 09-20-147 “Occupational Health Epidemiological Studies and EEOICPA Program Records.
HHS/CDC/NIOSH.” These records are treated in a confidential manner, unless otherwise compelled by law.
Disclosures that NIOSH may need to make for the processing of your petition or other purposes are listed

below.

NIOSH may need to disclose personal identifying information to: (a) the Department of Eneray, other federal
agencies, other government or private entities and to private sector employers to permit these entities to
retrieve records required by NIOSH; (b) identified witnesses as designated by NIOSH so that these
individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting
NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations;
(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a
Congressional staff member in response to a verified inquiry.

This notice applies to all forms and informational requests that you may receive from NIOSH in connection
with the evaluation of an SEC petition.

Use of the NIOSH petition forms (A and B) is voluntary but your provision of information required by these
forms is mandatory for the consideration of a petition, as specified under 42 CFR Part 83. Petitions that fail to
provide required information may not be considered by HHS.

Name or Social Security Number of First Petitioner: _



spent his entire career in the Carbon Products division. Prior to July 1, 1965 he appears
to have worked in clerical positions, e.g., Senior Clerk. Starting on July 1, 1965 and until
he retired he held a variety of positions in the Information Technology group starting as a
Program Analyst until his final position as Staff Analyst. During this time he worked in:

Niagara Falls, NY: Prior to September 1, 1959.

e

e Clarksburg, WV: September 1, 1959 — July 31, 1960

e Columbia , TN: August 1, 1960 — June 30, 1965

e Niagara Falls, NY: July 1, 1965 — August 31, 1984

e Clarksville, TN: September 1, 1984 — September 30, 1986.

If you have any further questions, please call the Retiree Service Center at (800) 334-
0661.

Sincerelv.


=> @

Union Carbide Corporation
A Subsidiary of The Dow Chemical many

February 27, 2008

This is in response to your letter that I received on February 5, 2008 requesting
information regarding retirement benefit. You also requested
information regarding his employment history at Union Carbide Corporation (“UCC”).

Date of Hire was September 29, 1952 and his adjusted Continuous

Service Date at UCC was March 18, 1953. This adjustment results from a brief period
where he was laid off. amployment ended on September 30, 1986 as a result
of the Voluntary Severance Program which included a “3 + 3” pension benefit
enhancement. The “3 + 3” enhancement added an additional 3 years to his age and
service for purposes of his pension calculation. When his employment at UCC ended,

actual age was 52 year, 10 months and actual service was 33 years, 6 months.
His “Application for Retirement Benefits” is enclosed.

elected to commence his pension benefit immediately on October 1, 1986. He
elected the 50% Joint and Survivor option (enclosed) and also elected the Level Income
option (enclosed). He received $2,079.55 per month prior to age 62 and was scheduled to
receive $1,477.55 per month after age 62 but passed away before this benefit became
effective. The survivor pension ($905.78) was based on his pension benefit prior to
processing his Level Income election. His pension calculation is enclosed.

passed away on. 1994 and your survivor pension ($905.78)
commenced on 1994. It was increased to $955.78 on September 1, 2007 as

a result of the recent pension adjustment,

According to our records management schedule, personnel files of employees are kent for
6 years plus the current year after an employee leaves employment. Therefore,
personnel file has been destroyed and I am unable to provide great detail of his
employment history with Union Carbide Corporation. However, there was some
information in his pension file that J can share with you (enclosed).

retired from the Carbon Products division at their facility in Clarksville, TN. His
last position was a Staff Analyst in the Information Technology group. It appears that he


Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Act Nationa! Institute for Occupational Safety and Health

7 . OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 6 of 7

F.3 QO IMWehave attached a report from a health physicist or other individual with expertise in
radiation dose reconstruction documenting the limitations of existing DOE or AWE records on
radiation exposures at the facility, as relevant to the petition. The report specifies the basis for
believing these documented limitations might prevent the completion of dose reconstructions for
members of the class under 42 CFR Part 82 and related NIOSH technical implementation
guidelines.

(Attach report to the back of the petition form.)

F.4 yi MWe have attached a scientific or technical report, issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuclear Regulatory
Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed
journal, that identifies dosimetry and related information that are unavailable (due to either a lack
of monitoring or the destruction or loss of records) for estimating the radiation doses of
employees covered by the petition.

(Attach report to the back of the petition form.)
Go to Part G.

g e of Pe e) ¢) g Pe fe} ° ete e o
All Petitighers should sign and date the petition. Amaximum of three persons maysign the petition.

y Signature *~ * Uv y , Law
Signature Date
Signature Date

Notice: Any person who knowingly makes any false statement, misrepresentation, concealment of

fact or any other act of fraud to obtain compensation as provided under EEQICPA or who
knowingly accepts compensation to which that person is not entitled is subject to civil or
administrative remedies as well as felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or imprisonment or both. | affirm that the information
provided on this form is accurate and true.

Send this form to: SEC Petition
Office of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226
if there are additional petitioners, they must complete the Appendix Forms for additional petitioners.
The Appendix forms are located at the end of this document.

Name or Social Security Number of First Petitioner:



Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Ocoupatignal, Centers for Disease Control and Prevention

ness Compensation Act 14-08 PO2:58 IN National Institute for Occupational Safety and Health
. OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 1 of 7

Use of this form and disclosure of Social Security Number are voluntary. Failure to use this form or disclose
this number will not result in the denial of any right, benefit, or privilege to which you may be entitled.

General instructions on Compieting this Form (complete instructions are avaiable in a separate packet):
Except for signatures, please PRINT all information clearly and neatly on the form.

Please read each of Parts A— G in this form and complete the parts appropriate to you. If there is more
than one petitioner, then each petitioner should complete those sections of parts A — C of the form that apply
to them. Additional copies of the first two pages of this form are provided at the end of the form for this pur-
pose. A maximum of three petitioners is allowed.

if you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

If you have questions about the use of this form, please call the following NIOSH toll-free phone number and
request to speak to someone in the Office of Compensation Analysis and Support about an SEC petition:
1-800-356-4674,

QA Labor Organization, StartatD on Page3

Ifyou O An Energy Employee (current or former), StartatC on Page2
are: ya Survivor (of a former Energy Employee), Start atB on Page2
GA Representative (of a current or former Energy Employee), StartatA on Page 1

A Representative Information — Complete Section A if you are authorized by an Employee or
Survivor(s) to petition on behalf of a class.

Al Are you a contact person for an organization? Q Yes (Go to A2) QO No (Go to A.3)

A2 Oreruzation Information:

Name okQvganation

AS
Mr./Mrs./Ms. First Name Middle initial Last Name
A4 _ Address:
Street Apt # P.O. Box
City State “aig Code
A5 Telephone Number: ( ) :

A6 Email Address:

AZ Check the box at left to indicate you have attached to the back of this form
petition by the survivor(s) or employee(s) indicated in Parts B or C of this form?

itten authorization to
n authorization

If you are representing a Survivor, go to Part B; if you are representing an. Employee, go to Part C.

Name or Social Security Number of First Petitioner: __


>.

‘|Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
lliness Compensation Act National Institute for Occupational Safety and Health

coe . OMB Number: 0920-0639 Expires: 05/31/2007
Petitioner Authorization Form Page 1 of 2

Use of this form is voluntary. Failure to use this form will not result in the denial of any right, benefit,

Instructions:

If you wish to petition HHS to consider adding a class of employees to the Special Exposure Cohort and you
are NOT either a member of that class, a survivor of a member of that class, or a labor organization
representing or having represented members of that class, then 42 CFR Part 83, Section 83.7(c) requires
that you obtain written authorization. You can obtain such authorization from either an employee who is a
member of the class or a survivor of such an employee. You may use this form to obtain such authorization
and submit the completed form to NIOSH with the related petition. Please print legibly.

For Further Information: If you have questions about these instructions, please call the following NIOSH
toll-free phone number and request to speak to someone in the Office of Compensation Analysis and
Support about an SEC petition: 1-800-356-4674.

Authorization for individual or Entity to Petition HHS on Behalf of a Class of Employees for

Addition to the Special Exposure Cohort

Name of Class Member or Survivor _

Street Address of Class Member or Survivor Apt. # P.O. Box

City, State, Zip Code of Vlass Member or Survivor

do herehe authariva:

Name of Petitioner _

Addréss of Petitioner = -Y / Apt. # P.O. Box

City, State and Zip Colle of Petitioner

to petition the Department of Health and Human Services on behalf of a class of employees
that includes:

Name of Class member (employee, not ine employee’s survivor)

for the addition of the class to the Special Exposure Cohort, under the Energy Employee’s
Occupational IfIness Compensation Program Act (42 U.S.C. §§ 7384-7385).

In providing this authorization, I recognize that the petitioner named above will have all the rights

of a netitioner as nrovided for under 42 CFR Part 83. f
- ~ Date s ’

—
Sign. - a

Name or Social Security Number of First Petitioner:



fea

Union Carbide Corporation

A Subsidiary of The Dow Chemical Company
Midland, Ml 48674
USA

Re:

Under a Service Agreement between The Dow Chemical Company and Union Carbide

Corporation. this letter is in response to your request dated 10/13/2008 regarding badge
records for In reviewing our records for Union Carbide. we

do not have any dosimetry — tilm badge or finger ring records for the sites
worked at for the time period he was employed.

Sorry we could not be of further assistance.



Special Exposure Cohort Petition U.S, Department of Health and Human Services

undef the Energy Employees Occupational Centers for Disease Control and Prevention
liness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 05/31/2007

pecial Exposure Cohort Petition — Form B Page 4 of 7
Proposed Definition of Employee Class Covered by Petiti

E.1 Name of DOE or AWE Facility: Efeteben Motel
E.2 Locations at the Facility relevant to this petition:

ndue  Kuilding (sb x ALZ\
d ~)

S|

Complete Section E.
ur aida
ray

E.3 _ List job titles and/or job duties of employees included in the class. In addition, you can list by
name any individuals other than petitioners identified on this form who you believe should be

included in this class:
uf  vomployee &

E.4. Employment Dates relevant to this petition:
Start § End 8/3 |; gq
Start End _

Start End
Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: Yes No

If yes, provide the date(s) of the incident(s) and a complete description (attach additional pages
as necessary):

Go to Part F.

Name or Social Security Number of First Petitioner: _ ee


Special Exposure Cohort Petition
under the Energy Employees Occupational
liness Compensation Act

Special Exposure Cohort Petition — Form B

U.S. Department of Heaith and Human Services
Centers for Disease Control and Prevention
National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007

Name of Organization

Position of Contact Person
D.2 Name of Petition Representative:

D3 Address of Petition Representa:

Street

Apt # P.O. Box

City State

(please attach documentation): Start

employees (if known):

D.4 Telephone Number of Petition Representative: ( » :
D.5 Email Address of Petition Representative:
D.6 Period during which labor organization represented emplo:

Zip Code

s covered by this petition

D.7__ Identity of other labor organizations that may represent or have rep!

ented this class of

Go to Part E.

Name or Social Security Number of First Petitioner:


Special Exposure Cohort Petition U.S, Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 05/31/2007

Ss}

pecial Exposure Cohort Petition — Form B Page 2 of 7
Survivor Information — Complete Section B if you are a Survivor or representing a Survivor.

B.1 Name of Survivor:

ULE,

First Name Middle initial Last Name
B.2  suna: sovwity Number of Survivor:

B.3. Address of Survivor:

Stee 2) ; Apt # P.O. Box

City © State Zip Code
B.4 Telephone Number of Survivor:
B.5 Email Address of Survivor:

B6 Relationship to Employee: Spouse Q Son/Daughter Q Parent
Grandparent Q Grandchild

Go to Part C.

Employee Information — Complete Secti LESS you are a labor organizati
C.1. Nama af Fmniavee: .

“First Name Middle Initial Last Name
C.2 Former ame of Employee (e.g., maiden name/legal name change/other):
Same
Mr/Mrs./Ms. First Name Middle Initial Last Name

C.3 Social Security Number of Employee: = _
C4 Address of Employee (if living):

Street Apt # P.O. Box
City State Zip Code
C.5 Telephone Number of Employee: )

C.6 Email Address of Employee:

C.7 Employment Information Related to Petition:

C7a Employee Number (if known):
C.7b Dates of Employment: Start y _ End g [3 fl [5 VA
C.7¢ Employer Name: Llecdtro - he fellas vr

C.7d Work Site Location: __A/yz gate “fi il. Wy.

C.7e Supervisor's Name: unknown

Go to Part E.

Name or Social Security Number of First Petitioner: _